POSTURE EXAMINATION FORM
Date: ______________
Name: _____________
Surname: ___________
Gender: M / F
Date of birth: ________
General Examination
a. Posterior view
1.
Achilles tendon and feet: Right _______ Left
2.
Knees (genu varum/genu valgum) _________
3.
Pelvic balance (posterior/superior iliac spine) _
4.
Scapulae (height, distance from spine, rotation)
5.
Shoulder line __________________________
6.
Neck ________________________________
7.
Symmetry of fat folds (pelvis, waist, neck) ___
8.
Spinal column (scoliosis) _________________
b. Lateral view
1.
Feet arches ___________________________
2.
Knees (hyperextension) _________________
3.
Pelvis (posterior/anterior tilt) ______________
4.
Spinal curves (kyphosis / lordosis / flat back) _
5.
Shoulder position ______________________
6.
Head position (cervical lordosis) ___________
c. Anterior view
1.
Feet ___________________
2.
Knees _________________
3.
Pelvis (anterior superior iliac spine)
4.
Shoulders height _________
5.
Neck/Head _____________
FUNCTIONAL TESTS
1.
Length of spinal column (C7-S1) _________________
Standing ___________ Forward bending __________
2.
General flexibility test ___________________________
Legs straight _________________________________
Forward bending with knees bent _________________
3.
Hamstrings flexibility (SLR): Right _____ Left _______
4.
Quadratus lumborum flexibility ____________________
5.
Thomas Test for iliopsoas flexibility: Right _ Left _____
6.
Abdominal muscle strength ______________________
7.
Ability to flatten lower back to floor (lying supine) ______
8.
Range of shoulder motion: Right ____ Left _________
9.
Length of lower extremities: Right ______ Left ______
10. Back
muscle strength: Cervical erectors ____________
Erector spinae ________________________________
Scapulae adductors ___________________________
11. Shoulder
girdle strength:
Abduction: Right _________ Left _____________
Adduction: Right _________ Left _____________
Flexion: Right _________ Left _____________
Extension: Right ________ Left _____________
12. Static
balance: Right leg ______ Left leg ___________
13. Dynamic
balance ______________________________
14. Forward
walking (general evaluation - broad/narrow support base, movement
balance, movement flow, coordination) _____________
X-rays, medical documents and previous diagnoses:
General evaluation:
Recommended treatment (indications/contraindications):
TREATMENT REPORT AND DEFINITION OF AIMS
Date ______________________
Name _____________________________________________________________
Age
Activity duration _____________________
Disorder treated
Type of activity: Individual/Group/Integrated (circle one)
Location of activity ________________________________
1.
Details of the problems requiring treatment (in reference to the
posture and motor tests).
2.
Other aspects affecting the persons condition and the
treatment process (reference to family, cognitive
emotional and social aspects, level of motivation,
cooperation, etc.)
3.
Treatment aims and content matter for the coming months:
a.
b.
Treatment summary report
Date ________________
Name _____________________________________ Age
Activity duration ____________________ Disorder treated
1.
Entry condition of the person at the beginning of treatment.
2.
Details of treatment goals and work method selected for
attaining them.
3.
Persons condition today (improvement/worsening of condition).
4.
Recommendations for further treatment of the person.
5.
General comments about treating the person.
Name of therapist/instructor
SELF-EXERCISE FORM
Name ___________________________________ Date
DETAILS OF EXERCISE (DRAWING) NUMBER OF REPETITIONS EMPHASIS
FOR PERFORMANCE
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